The differential effects of core stabilization exercise regime and conventional physiotherapy regime on postural control parameters during perturbation in patients with movement and control impairment chronic low back pain

Ramprasad Muthukrishnan, Shweta D Shenoy, Sandhu S Jaspal, Shankara Nellikunja, Svetlana Fernandes, Ramprasad Muthukrishnan, Shweta D Shenoy, Sandhu S Jaspal, Shankara Nellikunja, Svetlana Fernandes

Abstract

Background: The purpose of the present study was to examine the differential effect of core stability exercise training and conventional physiotherapy regime on altered postural control parameters in patients with chronic low back pain (CLBP). As heterogeneity in CLBP population moderates the effect of intervention on outcomes, in this study, interventions approaches were used based on sub-groups of CLBP.

Methods: This was an allocation concealed, blinded, sequential and pragmatic control trial. Three groups of participants were investigated during postural perturbations: 1) CLBP patients with movement impairment (n = 15, MI group) randomized to conventional physiotherapy regime 2) fifteen CLBP patients with control impairment randomized to core stability group (CI group) and 3) fifteen healthy controls (HC).

Results: The MI group did not show any significant changes in postural control parameters after the intervention period however they improved significantly in disability scores and fear avoidance belief questionnaire work score (P < 0.05). The CI group showed significant improvements in Fx, Fz, and My variables (p < 0.013, p < 0.006, and p < 0.002 respectively with larger effect sizes: Hedges's g > 0.8) after 8 weeks of core stability exercises for the adjusted p values. Postural control parameters of HC group were analyzed independently with pre and post postural control parameters of CI and MI group. This revealed the significant improvements in postural control parameters in CI group compared to MI group indicating the specific adaptation to the core stability exercises in CI group. Though the disability scores were reduced significantly in CI and MI groups (p < 0.001), the post intervention scores between groups were not found significant (p < 0.288). Twenty percentage absolute risk reduction in flare-up rates during intervention was found in CI group (95% CI: 0.69-0.98).

Conclusions: In this study core stability exercise group demonstrated significant improvements after intervention in ground reaction forces (Fz, Mz; g > 0.8) indicating changes in load transfer patterns during perturbation similar to HC group.

Trial registration: UTRN095032158-06012009423714.

Figures

Figure 1
Figure 1
Flowchart of participant recruitment, retention & interim analyses; *p < 0.05 and p < 0.016: Armitage-McPherson adjusted critical p values based on no. of interim analyses (k) i.e., for first and fifth interim analyses respectively.
Figure 2
Figure 2
Forces, Moments & COP displacements during perturbations before intervention in MI group compared to HC Group with independent 't' test results; * p < 0.016, HC-Healthy controls, MI-Movement impairment CLBP, CI-Control impairment CLBP, SD-Standard deviations.
Figure 3
Figure 3
Forces, Moments & COP displacements during perturbations after intervention in MI group compared to HC Group with independent 't' test results; * p < 0.016, HC-Healthy controls, MI-Movement impairment CLBP, CI-Control impairment CLBP, SD-Standard deviations.
Figure 4
Figure 4
Forces, Moments & COP displacements during perturbations before intervention in CI group compared to HC Group with independent 't' test results; * p < 0.016, HC-Healthy controls, MI-Movement impairment CLBP, CI-Control impairment CLBP, SD-Standard deviations.
Figure 5
Figure 5
Forces, Moments & COP displacements during perturbations after intervention in CI group compared to HC Group with independent 't' test results; * p > 0.016. HC-Healthy controls, MI-Movement impairment CLBP, CI-Control impairment CLBP, SD-Standard deviations.

References

    1. Ferreira PH, Ferreira ML, Christopher GM, Herbert RD, Kathryn R. Specific stabilization exercises for spinal and pelvic pain: a systematic review. Aust J Physiother. 2006;52:70–88.
    1. Henry T, Hodges PW. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. J Electromyogr Kinesiol. 2008;18:559–567. doi: 10.1016/j.jelekin.2006.10.012.
    1. O'Sullivan PB, Twomey L, Allison GT. Altered abdominal muscle recruitment in patients with chronic back pain following a specific exercise intervention. J Orthop Sports Phys Ther. 1998;27:114–24.
    1. Tsao H, Hodges PW. Immediate changes in feedforward postural adjustments following voluntary motor training. Exp Brain Res. 2007;4:537–546. doi: 10.1007/s00221-007-0950-z.
    1. Tsao H, Gales M, Hodges PW. Reorganisation of the motor cortex in chronic low back pain. J Bone Joint Surg Br. 2009;91-B:428–A.
    1. Arokoski JP, Valta T, Kankaanpaa M, AAiraksinen O. Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients. Arch Phys Med Rehabil. 2004;85:823–32. doi: 10.1016/j.apmr.2003.06.013.
    1. Zazulak B, Cholewicki J, Reeves NP. Neuromuscular Control of Trunk Stability: Clinical Implications for Sports Injury Prevention. J Am Acad Orthop Surg. 2008;16:497–505.
    1. Granata KP, Wilson SE. Trunk posture and spinal stability. Clin Biomech. 2001;16:650–659. doi: 10.1016/S0268-0033(01)00064-X.
    1. Bazrgari A, Shirazi-Adl C, Lariviere. Trunk response analysis under sudden forward perturbations using a kinematics-driven model. J Biomech. 2009;42:1193–1200. doi: 10.1016/j.jbiomech.2009.03.014.
    1. Radebold A, Cholewicki J, Polzhofer GK, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine. 2001;26(7):724–730. doi: 10.1097/00007632-200104010-00004.
    1. Cholewicki J, Polzhofer GK, Radebold A. Postural control of trunk during unstable sitting. J Biomech. 2000;33(12):1733–1737. doi: 10.1016/S0021-9290(00)00126-3.
    1. Liddle SD, Gracey JH, Baxter GD. Advice for the management of low back pain: a systematic review of randomised controlled trials. Man Ther. 2007;12:310–327. doi: 10.1016/j.math.2006.12.009.
    1. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005;85:209–225.
    1. Cairns, Mindy C, Foster, Nadine E, Wright, Chris. Randomized Controlled Trial of Specific Spinal Stabilization Exercises and Conventional Physiotherapy for Recurrent Low Back Pain. Spine. 2006;31:E670–E681. doi: 10.1097/01.brs.0000232787.71938.5d.
    1. O'Sullivan PB. Diagnosis and classification of chronic low back pain disorders: maladapitve movement and motor control impairments as underlying mechanism. Man Ther. 2005;10:242–255. doi: 10.1016/j.math.2005.07.001.
    1. Dankaerts W, O'Sullivan PB, Burnett A, Straker L. Altered patterns of superficial trunk muscles activation during sitting in nonspecific chronic low back pain patients: importance of subcalssification. Spine. 2006;31:2017–2023. doi: 10.1097/01.brs.0000228728.11076.82.
    1. Christopher JS, Stanley AH. Expert opinion and controversies in musculoskeletal and sports medicine: core stabilization as a treatement for low back pain. Arch Phys Med Rehabil. 2007;88:1734–1736. doi: 10.1016/j.apmr.2007.10.002.
    1. Dankaerts W, O'Sullivan PB, Straker LM, Burnett AF, Skouen JS. The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment. Manual Therapy. 2006;111:28–39. doi: 10.1016/j.math.2005.02.001.
    1. O'Sullivan PB. Lumbar segmental 'instability': clinical presentation and specific stabilizing exercise management. Manual Therapy. 2000;5:2–12. doi: 10.1054/math.1999.0213.
    1. Brouwer S, Kuijer W, Dijkstra PU, Goeken LN, Groothoff JW, Geertzen JH. Reliability and stability of the Roland Morris Disability Questionnaire: intra class correlation and limits of agreement. Disabil Rehabil. 2004;26:162–165. doi: 10.1080/09638280310001639713.
    1. Costa LO, Maher CG, Latimer J, Ferreira PH, Ferreira ML, Pozzi GC, Freitas LM. Clinimetric testing of three self-report outcome measures for low back pain patients in Brazil: which one is the best? Spine (Phila Pa 1976) 2008;33:2459–2463.
    1. Rouwer S, Kuijer W, Dijkstra PU, Göeken LN, Groothoff JW, Geertzen JH. Reliability and stability of the Roland Morris Disability Questionnaire: intraclass correlation and limits of agreement. Disabil Rehabil. 2004;26:162–5. doi: 10.1080/09638280310001639713.
    1. Cleland JA, Fritz JM, Childs JD. Psychometric properties of the Fear-AvoidanceBeliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with neck pain. Am J Phys Med Rehabil. 2008;87:109–117. doi: 10.1097/PHM.0b013e31815b61f1.
    1. Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, Vlaeyen JW, Oostendorp RA. Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Man Ther. 2003;8:29–36. doi: 10.1054/math.2002.0484.
    1. Dixon D, Pollard B, Johnston M. What does the chronic pain grade questionnaire measure? Pain. 2007;130:249–53. doi: 10.1016/j.pain.2006.12.004.
    1. Elliott AM, Smith BH, Smith WC, Chambers WA. Changes in chronic pain severity over time: the Chronic Pain Grade as a valid measure. Pain. 2000;88:303–308. doi: 10.1016/S0304-3959(00)00337-7.
    1. Smith BH, Penny KI, Purves AM, Munro C, Wilson B, Grimshaw J, Chambers WA, Smith WC. The Chronic Pain Grade questionnaire: validation and reliability in postal research. Pain. 1997;71:141–7. doi: 10.1016/S0304-3959(97)03347-2.
    1. Myles PS, Sally T, Michael B, Reeves M. The Pain Visual Analog Scale: Is It Linear or Nonlinear? Anesth Analg. 1999;89:1517. doi: 10.1097/00000539-199912000-00038.
    1. Boeckstyns ME, Backer M. Reliability and validity of the evaluation of pain in patients with total knee replacement. Pain. 1989;38:29–33. doi: 10.1016/0304-3959(89)90069-9.
    1. Jensen MP, Karoly P, O'Riordan EF, Bland F, Burns RS. The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain. 1989;5:153–159. doi: 10.1097/00002508-198906000-00005.
    1. Christopher JH, Richard EA, Van Emmerik, Graham EC. Predicting dynamic postural instability using center of mass time-to-contact information. J Biomech. 2008;41:2121–2129. doi: 10.1016/j.jbiomech.2008.04.031.
    1. Kuukkanen TM, Malkia EA. An experimental controlled study on postural sway and therapeutic exercise in subjects with low back pain. Clin Rehabil. 2000;14:192–202. doi: 10.1191/026921500667300454.
    1. Ludbrook J. Interim analyses of data as they accumulate in laboratory experimentation. BMC Med Res Methodol. 2003;3:15. doi: 10.1186/1471-2288-3-15.
    1. Todd S, Whitehead A, Stallard N, Whitehead J. Interim analyses and sequential designs in phase III studies. Br J Clin Pharmacol. 2001;5:394–9. doi: 10.1046/j.1365-2125.2001.01382.x.
    1. Ellen LC, Maureen SJ, Bruce ER, Stephen MG. Influence of pain distribution on gait characteristics in patients with low back pain: part 1: vertical ground reaction force. Spine. 2007;32:1329–1336. doi: 10.1097/BRS.0b013e318059af3b.
    1. Butcher SJ, Craven BR, Philip DC, Kevin SS, Groan SL, Eric JS. The effect of trunk stability training on vertical takeoff velocity. Orthop Sports Phys Ther. 2007;37:223–231.
    1. Milles JD, Taunton JE, Mills WA. The effects of a 10 week training regimen on lumbo-pelvic stability and athletic performance in female athletes: a randomized controlled trial. Phys Ther Sport. 2005;6:60–66. doi: 10.1016/j.ptsp.2005.02.006.
    1. Henry SM, Fung J, Horak FB. Effect of stance width on multidirectional postural responses. J Neurophysiol. 2001;85:559–570.
    1. Gelsy TO, Ting LH. Muscle Synergies characterizing Human Postural Responses. J Neurophysiol. 2007;98:2144–2156. doi: 10.1152/jn.01360.2006.
    1. Feise RJ. Do multiple outcome measures require p-value adjustment? BMC Med Res Methodol. 2002;17(2):8. doi: 10.1186/1471-2288-2-8.
    1. Runge LA, Pinals RS, Tomar RH. Treatment of rheumatoid arthritis with levamisole: long-term results and immune changes. Ann Rheum Dis. 1979;2:122–7. doi: 10.1136/ard.38.2.122.
    1. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;6:393–403.
    1. Meyhoff CS, Wetterslev J, Jorgensen LN, Henneberg SW, Simonsen I, Pulawska T, Walker LR, Skovgaard N, Heltø K, Gocht-Jensen P, Carlsson PS, Rask H, Karim S, Carlsen CG, Jensen FS, Rasmussen LS. PROXI TrialGroup. Perioperative oxygen fraction - effect on surgical site infection and pulmonary complications after abdominal surgery: a randomized clinical trial. Rationale and design of the PROXI-Trial. Trials. 2008;9:58. doi: 10.1186/1745-6215-9-58.
    1. Oggero E, Pagnacco G, Morr DR, Berme N. How force plate size influences the probability of valid gait data acquisition. Biomed Sci Instrum. 1999;35:3–8.

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